Obstetrical Fistulas Andreea Creanga, M.D. Rene Genadry, M.D. Obstetrical Fistulas Preventable Treatable 1 Obstetrical Fistulas Result from prolonged, obstructed and neglected labor Coupled with a lack of medical intervention to relieve it Obstetrical Fistulas Definition Tissue destruction due to prolonged pressure of the head during obstructed labor (ischemic lesion). Tissue laceration during instrumental delivery, cesarean section or cesarean hysterectomy. 2 Maternal Morbidity & Mortality WHO, 2005 Maternal Mortality Ratios WHO, 2005 3 Objectives Overview clinical literature Review reported evaluation, management and outcomes Identify complications of treatment Introduce elements of classification Propose clinical points of discussion Key Points Overview Evaluation issues Management issues Outcomes issues Unresolved issues 4 Overview Obstetrical Fistulas Obstructed neglected labor Difficult operative delivery Traditional surgical practices Pelvic immaturity Nutritional deficiencies Socio-cultural factors 5 Predisposing Conditions Early age at labor with pelvic immaturity Android or anthropoid pelvis Genital mutilation Cultural and social factors impeding care Economic factors impeding access and availability of care Fistula Development (I) Anterior vaginal wall, bladder base and urethra are compressed between the fetal head and the posterior surface of the pubis In prolonged obstructed labor, pressure necrosis of the anterior vaginal wall and the underlying bladder neck occurs More extensive necrosis involves urethra, trigone and anterior cervix 6 Fistula Development (II) If mother survives, a macerated fetus is expelled 3-4 days later Sloughing of devitalized tissue (bladder, vagina) 10 days later Wide area of pressure results in an anatomical area widely affected by scarring and devascularization Types of Obstetrical Fistulas (Elkins) Vesicouterine(cervical)-c/s and inlet Juxtacervical- obstruction at pelvic intlet Midvaginal- midpelvic obstruction Suburethral- base of pubic bone Total urethral loss- obstruction at pelvic outlet Combined VVF-RVF- long and obstructed labor Ureterovaginal-C/S & C/H 7 Obstetric Labor Injury Complex Urological Gynecological Rectal Orthopedic Neuro-vascular Dermatological Psychological Arrowsmith, Hamlin & Wall, 1996 Extent of Injury Isolated VVF are more common than combined VVF & RVF (n=309) – 78 % VVF, 15% VVF & RVF, 7% RVF – 70% complicated Much scarring Total destruction of urethra Ureteric orifices at edge or outside fistula Small bladder VVF & RVF Presence of calculi Kelly, 1993 8 Obstetrical Fistulas Very little scientific research published – Remote areas – Limited resources Only one RCT (n=79) on IV AB - no benefit regarding success or incontinence One comparative retrospective study (n=49) - better results with Martius Unresolved Issues - Epidemiology - No standard data collection – Facility vs. Population based No standard reporting – Difficult cross-study comparisons No supported conclusion on impact of: – Decreasing age of marriage – Delaying the first birth – Family planning use – Antenatal and birth care 9 Unresolved Issues -Physiopathology- No studies on fistula prevention and role of: – Age – Parity – Degree of necrosis No standard classification Evaluation Issues Low tech Complete 10 Historical Periods “Pre-leak” (1000 BC-1300 AD ) “Mend-the-leak” (1300-1940) “Mega-leak” (1940-1990) “Para-leak” (1990-2000) “Never-leak” (2000Î) Elkins, 1997 Investigation Confirm extraurethral urinary leakage Visualize leakage site(s) Assess vaginal mobility, length & scars Assess bladder capacity, neck and upper tract Assess perineum Use liberal sedation or EUA 11 Physical Findings in VVF 123 patients with VVF (Senegal) 10 associated fistulas 5 vesicouterine fistulas 4 rectovaginal fistulas 1 ureterovaginal fistula 50% associated lesions (vagina, urethra, bladder, perineum) 34% radiological anomalies Gueye, Gueye, 1992 Preoperative Considerations Accurate diagnosis Recognize associated abnormalities Timing of surgery 12 Associated Pathology (I) Sphincteric abnormalities Secondary fistula Urethral defects Ureteral fistula / obstruction Coexistent ureteric injuries in 10-15% of patients with VVF Frequency of Urethral Destruction Author Year # cases Couvelaire 1953 131 % urethral destruction 20.6 Carayon et al. 1962 225 52.0 Docquier 1982 280 24.2 Chiche et al. 1983 578 9.8 Benchekroun et al. 1987 600 31.0 Loran et al. 1991 903 9.1 Falandry 1996 672 17.7 13 Associated Pathology (II) Genital prolapse Low bladder compliance Detrusor instability Unresolved Issues -Diagnosis- No standard evaluation No standard identification of co-morbidities – Foot drop – Fecal incontinence – POP – UTI – Amenorrhea – Sexual dysfunction 14 Management Issues Preventive measures Optimal approaches Comprehensive care Management Immediate drainage Local cutaneous care +/- infection treatment Nutritional care Counseling and consent Surgical treatment Postoperative care Rehabilitation and reintegration 15 Preoperative Care Adequate diagnosis Treat infections (schistosomiasis, malaria, TB, LGV) Treat anemia Good nutrition Estrogen therapy Remove stones (6 weeks) AB ? (RCT - Tomlinson, 1998) Timing of Repair Î First attempt most successful! Mature fistula concept - Sims – 2-4 months – Initial drainage results in few closures Immediate repair to prevent social ostracism – 170 consecutive patients <3 months – Closure (n=156) & continence (n=146) - Waaldjik 16 Early Repair Exam every 2 weeks for pliabilityusually 4-8 weeks after injury (Carr & Webster, 1996) In recurrent fistulas, liberal use of Martius graft and interval 3-6 months post repair (Rangnekar et al., 2000) Route of Repair Vaginal Abdominal Combined (vaginal & abdominal) ? Laparoscopic 17 General Principles of Repair Adequate operative exposure Tension free, multiple layer closure Bladder drainage +/- Pedicle graft interposition Vaginal Repair Preferred method Absence of need for abdominal repair 18 Indications for Vaginal Repair Simple fistula Urethral fistula Absent CI: – Poor exposure – Vaginal scarring & stenosis – Small bladder – Abdominal pathology – Need for ureteral reimplantation Abdominal Repair Most complex fistulas Complicated fistulas Disadvantage: – Cost – Complications 19 Indications For Abdominal Repair Insufficient vaginal size Inadequate operative exposure Ureteral fistula / obstruction Access omental graft Concomitant abdominal pathology Low bladder compliance Operative Technique -Abdominal Repair- Catheterize ureters Circumscribe fistula Dissect bladder wall flaps Omental interposition 20 Combined Repair When single route inadequate (poor exposure) or insufficient (not successful) When previously failed trigonal or supratrigonal repair When omental interposition necessary while fistula exposed from below Requirements For Successful Technique (I) Freedom from local infection/inflammation Identification of all fistulas and pathology Adequate exposure Wide mobilization of vagina & bladder Fistula excision not always necessary Use of appropriate suture material outside bladder mucosa 21 Requirements for Successful Technique (II) Tension-free closure of bladder (multiple layers) Graft when indicated Post-operative bladder drainage Continent diversion may be necessary after multiple failed attempts ? When primary diversion Surgical Graft Techniques Labial fat and BC muscle(Martius) Full thickness labial graft Rectus muscle flap Gracilis muscle Omental pedicle Peritoneal flap Free blabber mucosal autograft No randomized data 22 Urinary Diversions Extremely limited acceptability– 0.6% of 2484 patients (Hilton/Nigeria) Short and long term morbidity – 1/7 fatality; 1/7 reoperation day 10 Risk of metabolic, infectious, obstructive and renal disorders Long term complications in remote situations (Hodges/Uganda) Postoperative Care Adequate bladder drainage 2-3 weeks High fluid input and output Postoperative AB prophylaxis Avoid excessive activity 4-6 weeks Perineal hygiene Pelvic rest 3 months 23 Complications of Treatment Persistent incontinence Gynatresia Dyspareunia Ureteric injury Irritative lower tract symptoms Small scarred bladder Postoperative Morbidities Amenorrhea Anuria Atresia Bladder stones Gynatresia Incontinence (urinary or fecal) Leg weakness Superficial wound infection Urinary retention Urinary tract infection 24 Amenorrhea Pituitary-hypothalamic dysfunction (63%) Asherman’s syndrome Sheehan’s syndrome PID Amenorrhea several months to 15 yrs in 66 patients; in 55 of these, menses returned within 6 months after repair. (Evoh, 1979) Postoperative Complications (I) 56 patients repaired – 10 mild SUI, 3 type II, 5 type III – 8 DI – 8 Gynatresia – 10 dyspareunia – 8 foot drop – 4 amenorrhea Elkins, 1994 25 Postoperative Complications (II) When at UVJ: – 40% SUI – 2% vs. 20% hemorrhage when juxtacervical When midvaginal: – 60% gynatresia &/or – small bladder with instability Elkins, 1994 Management Factors Comprehensive evaluation Fixity of vaginal structures Experience and surgical skills Previous attempts Late referral Mobilization of tissues Layer closure without tension Treat infections: malaria, TB, LGV, Schistosomiasis 26 Unresolved Issues -Management- Timing of repair Route of repair Newer techniques Techniques for incontinence Postoperative care Unmet needs of surgical treatment Management of complications Outcome Issues Predictive factors Definition of success Standard reporting 27 Overall Success Rates Author Wachawan Rathee Falandry Ghororo Enquete Afu Docquier Benchekroun Rafique Gueye Bhattacharya Kelly & Kwast Muleta Elkins Hilton Waaldjik # cases 163 49 261 48 418 394 598 42 111 62 309 1210 100 2484 1716 % success 59.1 71.4 81.2 81.3 82.0 83.0 84.0 85.7 86.0 87.1 88.0 92.6 95.0 97.7 98.5 Outcome- Primary Repair (I) Approach Procedure Transvaginal flapsplitting Martius Latzko Martius Latzko + Martius Mobilization + Martius Mobilization Vaginal Vaginal Modified Martius flap Chassar Moir Author Year # cases Success rate (%) Wadhawan 1983 82 59.1 Elkins 1988 31 77.0 Iloabachie 1989 64 70.0 Elkins 1990 25 96.0 % Incontinence Enzelberger 1991 42 98.0 Latzko Carreras 2001 27 87.0 Chassar Moir Martius Falandry 1992 230 87.4 7.4 Kelly 1998 1138 84.7 9.0 Martius Gracilis muscle Urethral reconstruction Ureter reimplantation 28 Outcome- Primary Repair (II) Author Year Total # cases Success rate (%) Vesical autoplasty; transvesical, extraperitoneal or transperitpneovesical Gil-Vernet 1989 39 100.0 Transvesical, simple layered Motiwala 1991 58 95.0 Motiwala 1991 10 90.0 Modified O’Conor – transvesical, no flap Moriel 1993 16 100.0 O’Conor Demirel 1993 17 94.0 Approach Procedure Abdominal Transperitoneal +/- omental flap Outcome Primary Repair Unreported procedures Year Total # cases Success rate (%) Incontinence (%) after successful closure Bird 1967 70 71.0 10.0 Ashworth 1973 152 74.0 12.0 Kelly 1983 248 83.0 10.0 Ahmad 1988 325 61.0 - Martey 1989 100 95.0 - Ojengbede 1989 150 90.0 - Lawson 1989 369 75.0 - Waaldijk 1989 500 88.0 11.0 Ward 1989 1789 85.0 - Kelly & Kwast 1993 309 88.0 6.2 Waaldijk 2004 1716 95.2 6.5 Author 29 Outcome No standard definition of success! – Closure of fistula – Repair incontinence – Restore ability to have sexual intercourse – Return of menstruation – Re-integration into society Predictors of Adverse Outcome Subjective observations of moderate to severe scarring or damage to urethra or bladder neck (Arrowsmith) Type of fistula and state of perifistular tissues, but also 1st procedure (Gueye) Location most significant (Gassessew) # previous attempts, severity, health, facilities, experience & expertise (Kelly) 30 Differences between fistula repairs resulting in failure or cure at the Addis Ababa Fistula Hospital 1987-1988 Failure (n=71) Cure (n=1096) Fistula characteristics RUPTURED UTERUS LIMB CONTRACTURES PREOPERATIVE FEEDING ≥ 4 ATTEMPTS AT REPAIR TRANSFUSION BLOOD/PLASMA ANESTHESIA IN ADDITION TO SPINAL FISTULA COMPLICATED (much scarring, total destruction of the urethra, ureteric orifices at the edge of, or outside the fistula, small bladder, RVF associated, calculi) * # % # % 12 6 26 7 64 58 17.1 8.5 38.6 9.9 90.1 81.7 48 21 78 12 517 446 4.4* 1.9* 7.1* 1.1* 47.2* 40.7* 71 100.0 639 58.3** p<0.001; ** p<0.0005 Kelly & Kwast, 1993 Outcome With Graft Martius flap (n=21) Type of fistula Urethrovaginal fistula involving bladder neck (n=12) Vesicovaginal fistula (n=34) Anatomic repair (n=25) Heale d Incontine nt Failure Healed Incontinen t Failur e 7 0 1 1 1 3 13 0 0 17 1 4 Rangnekar et al., 2000 31 Outcome- Recurrent Fistulas # repairs Type of prior procedure Procedure at last repair attempt 1-7 Abdominal Abdominal (vesical autoplasty, omental graft) 1-3 Abdominal (O’Conor) Or Vaginal (Martius) Abdominal (O’Conor) Or Vaginal (Martius) 1 2 Unreported procedures 1 2 ≥3 Unreported procedures Author Year # cases Success rate (%) Gil-Vernet 1989 42 100.0 Arrowsmith 1994 98 96.0 Hilton 2003 2484 81.0 65.0 Lawson 1989 54 30 9 70.0 66.7 33.3 Treatment Success When is success defined: – At discharge? 7-14 days – Long term? > 6 months Single vs. Multiple repair operations: – Report success for 1st, 2nd, 3rd, etc – Report success combined rate for all operations 32 Outcome - # Procedures Outcome & # procedures % patients % cumulative Dry (1) 81.0 % (n=79) 81.0 % Dry (2) 8.0 % (n=8) 89.0 % Dry (3) 4.0 % (n=4) 93.0 % Dry (>3) 3.0 % (n=3) 96.0 % Incontinent 4.0 % (n=4) Total 100.0 % (n=98) Arrowsmith, 1993 Fistula Cure For a 100% cure, the following conditions must be fully satisfied: – Complete continence by day and night – Bladder capacity> 170ml – No SIU – Normal coitus without dyspareunia – No traumatic amenorrhea – Ability to bear children Coetzee & Lightgow, 1996 33 Subsequent Pregnancy (I) C/S 12 of 33 patients pregnant within 1 year of repair delivered vaginally Criteria for vaginal delivery: – Non-recurring cause of obstructed labor – Graft interposition at closure – In-hospital closely supervised delivery Kelly, 1979 Subsequent Pregnancy (II) Determinant factors of success – Antenatal supervision, nutrition, UTI Rx – Improved maternal education Elective C/S for all fistula patients Elements of continued improvement – Continued education against harmful sociocultural practices that prevent antenatal care and early use of Ob care Emembolu, 1992 34 Unresolved Issues -Outcome No standard definition of cure No standard classification No standard reporting system – Time – Number of procedures and type – Type of fistula repair – Associated morbidities Classification Anatomy Function Surgical complexity Outcome predictability 35 Classification systems for VVF Year Author Classification 1852 Simms 1. UethroUethro-vaginal, confined to urethra 2. Fistula at bladder neck or root of urethra 3. Body & floor of bladder destroyed 4. UteroUtero-vesical fistula 1958 McConnachie Grade 1: Normal, healthy tissues Grade 2: Mild scarring Grade 3: More scarring, poor vaginal access Grade 4: Repeat repair Grade 5: Inoperable per vagina Type A: Less than 1 cm diameter Type B: Over 1 but less than 2 cm diameter Type C: Over 2 cm diameter Type D: Any of above type with rectovaginal fistula Year Author Classification 1969 Hamlin & Nicholson 1. Simple vesicovesico-vaginal fistula 2. Simple rectorecto-vaginal fistula 3. Simple urethraurethra-vaginal fistula 4. VesicoVesico-uterine fistula 5. Difficult high rectorecto-vaginal fistula 6. Difficult urinary fistula - complex 1972 Lawson 1. Juxtaurethral 2. Vault 3. MidMid-vaginal 4. Juxtacervical 1985 Tahzib 1. JuxtaJuxta-urethral 2. MidMid-vaginal 3. High 4. Massive 5. Other 36 Year Author Classification 1992 Gueye 1. SimpleSimple- far from ureters, urethra intact 2. Complex – partial or total loss of urethra 3. Complicated – total loss of urethra +/+/- RVF 1992 Iloabachie 1. Juxta urethral 2. Juxta cervical 3. Gynecological 4. Giant fistula 5. Mid vaginal 6. Vesico uterine Year Author Classification 1994 Elkins 1. VesicoVesico-cervical 2. JuxtaJuxta-cervical 3. MidMid-vaginal vesicovesico-vaginal 4. SubSub-urethral vesicovesico-vaginal 5. UrethroUrethro-vaginal 1995 Waaldijk I - fistula not involving closing mechanism IIAa– IIAa– fistula involving closing mechanism, without (sub)total urethra & without circumferential defect IIAb– IIAb–fistula involving closing mechanism, without (sub)total urethra & with circumferential defect IIBa– IIBa–fistula involving closing mechanism, with (sub)total urethra & without circumferential defect IIBb– IIBb–fistula involving closing mechanism, with (sub)total urethra & with circumferential defect III - involving ureter & other exceptional fistulas 37 Year Author Classification 1994 Hilton 1. Simple 2. Complex – poor access for repair, significant tissue loss, ureteric involvement, coexistent RVF. 2004 Browning 1. Simple -minimal vaginal scarring and good bladder volume 2. Complex -severe vaginal scarring and /or reduced bladder volume, needing some degree of vaginoplasty or even reconstruction of the vagina. 2004 McKay 1. Simple 2. Complex, fistulas involving other organs: urethra, ureter, uterus, rectum Year 2004 Author Goh Classification Type 1: Distal edge of fistula > 3.5 cm from external urinary meatus meatus Type 2: Distal edge of fistula 2.52.5- 3.5 cm from external urinary meatus Type3: Distal edge of fistula 1.51.5-<2.5 cm from external urinary meatus Type 4: Distal edge of fistula < 1.5 cm from external urinary meatus meatus (a) Size < 1.5 cm, in the largest diameter (b) Size 1.51.5-3 cm, in the largest diameter (c) Size > 3 cm, in the largest diameter i. None or only mild fibrosis (around fistula and/or vagina) and/or and/or vaginal length > 6 cm, normal capacity ii. Moderate or severe fibrosis (around fistula and/or vagina) and/or and/or reduced vaginal length and/or capacity iii. Special consideration e.g postradiation, postradiation, ureteric involvement, circumferential fistula, previous repair 2005 Chapple 1. Simple – the healing quality of the tissue margins are virtually normal and these can be resolved by simple, meticulously sutured, sutured, layer closure. 2. Complex – recurrent fistulas, fistulas with extensive tissue loss, developmental deficiencies, impaired healing potential of its margins, all fistulas that involve the sphincter mechanism, postpostobstetric and urethraurethra-vaginal. 38 Classification systems for RVF Year Author Classification 1980 Rosenshein I-loss of perineal body not associated with an identifiable fistulous fistulous tract IIII-loss of perineal body associated with a fistulous tract involving involving the lower third of the vagina IIIIII-fistulas involving the lower third of the vagina with an intact or attenuated perineal body. IVIV-fistulas involving the middle third of the vagina V-fistulas involving the upper part of the vagina 2004 Goh Type 1: Distal edge of fistula > 3.5 cm from hymen Type 2: Distal edge of fistula > 3.5 cm from hymen Type3: Distal edge of fistula > 3.5 cm from hymen Type 4: Distal edge of fistula > 3.5 cm from hymen (a) Size < 1.5 cm, in the largest diameter (b) Size 1.51.5-3 cm, in the largest diameter (c) Size > 3 cm, in the largest diameter i. No or mild fibrosis around fistula and/or vagina ii. Moderate or severe fibrosis iii. Special consideration e.g. postradiation, postradiation, previous repair. Classification Comparative assessment of the published fistula literature is currently impossible – No accepted standardized method – Previously based on type, size and site – No definition of terminology used 39 Classification Issues Size (length and width) Location Degree of vaginal scarring Number of fistulas Attachment to pelvic wall Condition of urethral sphincter Location of ureteral orifices Complicating factors: RVF, inflammation VVF Type Simple Complex Complicated 40 Simple VVF Characteristics Single opening Less than 2 cm Minimal scarring Vagina > 6 cm Complex VVF Characteristics Multiple openings 2 - 4 cm in size Failed previous repair Moderate scarring; scarred trigone, UVJ Vagina <4 cm Partially absent urethra Vesicocervical (uterine) 41 Complicated VVF Characteristics Over 4 cm in size Short vagina (<4 cm) Absent urethra Reduced bladder capacity Ureteral involvement RVF Severe scarring VVF Site Urethral Trigonal Supratrigonal Urethrotrigonal 42 VVF Classification Type I- Simple Type II – Complex Type III – Complicated A - Urethral B - Trigonal C - Supratrigonal D - Urethrotrigonal - 1, 2, 3... # repair attempts Conclusions Urgent need for prevention Urgent need for standard classification Need for management protocols Need for training Need for research 43 Unresolved Issues -Topics for Discussion- Simple fistulas Complex fistulas Complicated fistulas Complications of fistula treatment Simple Fistulas (I) Role of preventive bladder drainage Preoperative care Optimal length of postoperative drainage Postop care and recurrence prevention Incontinence management Long term follow-up of repaired fistulas 44 Simple Fistulas (II) Optimal low-tech repair & training Criteria for referral When to use graft When to use an abdominal route Newer techniques Long term true success Fate of subsequent pregnancy Complex Fistulas (I) Frequency and incidence of associated injuries Frequency of upper tract abnormalities Role of ureteral catheterization Optimal grafting When to sling concomitantly 45 Complex Fistulas (II) When to augment bladder or substitute When to augment vagina and how When to combine approaches How many repeats When to consider diversion Urethral reconstruction Complete urethral loss Complicated Fistulas (I) What diagnostic studies When primary diversion and which Optimal approach to RVF Role of augmentation graft Assessment of defecatory dysfunction Associated injuries 46 Complicated Fistulas (II) Where to carry out complex procedures Optimal follow-up of diverted patients Long term studies on sexual function Optimal skin care Children issues Complications of Repair (I) Vaginal Atresia – – – – Optimal approach, vaginal, abdominal Optimal material Long term results Functional results Urinary Diversion – – – – – Long term followfollow-up Optimal followfollow-up Morbidity and mortality Optimal reimplantation Mobile vs. Fixed units 47 Complications of Repair (II) Urinary Incontinence – Incidence of neurologic dysfunction – Incidence of contracted bladder – Optimal sphincter repair and timing – When and what sling – When and what augmentation Criteria FollowFollow-up Material A Call to Action Training Research Specialized centers Early intervention Prevention 48 I am old, and need to remember. You are young, and need to learn. If I forget the words, will you remember the music? Ashanti proverb Thank You! 49
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